2015 HSC Section 1 Book of Articles

Reprinted by permission of JAMA Otolaryngol Head Neck Surg. 2014; 140(3):233-236.

Research

Original Investigation

A Retrospective Review of the Progression of Pediatric Vocal Fold Nodules

Heather C. Nardone, MD; Thomas Recko, BA; Lin Huang, PhD; Roger C. Nuss, MD

IMPORTANCE To our knowledge, the rate of change in the size of pediatric vocal fold nodules (VFNs) has not been investigated. Improved understanding of the factors that affect change in VFN size may help to better guide treatment decisions and counselling of families.

OBJECTIVE To characterize the rate of change in the size of pediatric VFNs over time and to identify which factors affect increased rates of improvement.

DESIGN, SETTING, AND PARTICIPANTS Retrospective review of 67 children evaluated in a voice clinic between 2002 and 2011 with a primary diagnosis of VFNs.

EXPOSURE No treatment or behavioral modification only (n = 19) vs targeted voice therapy with or without the treatment of associated conditions (gastroesophageal reflux and allergic rhinitis) (n = 45) vs surgical intervention (n = 3).

MAIN OUTCOMES AND MEASURES Change in VFN grade (graded according to a previously validated scale based on size) over time.

RESULTS Sixty-seven patients with a median (range) age of 6.0 (3.8-20.6) years were analyzed. Median (range) follow-up was 25 (1-119) months. The rate of change in VFN grade over time was significantly associated with large baseline VFN size ( P < .001) and targeted voice therapy with or without the management of associated conditions or surgery ( P = .01); the association with postpubescent age was not significant ( P = .09). The rate of change in VFN grade was not significantly different at 1 and 3 years postbaseline ( P = .33). CONCLUSIONS AND RELEVANCE Baseline VFN size, treatment, and patient age are important in predicting the rate of improvement in nodule size over time. Rate of change in VFN size is a gradual decrease that is steady over time. This information can be used to help guide treatment decisions and counsel families of children with VFNs regarding expectations for improvement. Additional study is needed to evaluate whether the same factors that influence nodule size similarly influence parental perception of voice and expert perceptual voice analysis.

Author Affiliations: Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (Nardone); Department of Otolaryngology and Communication Disorders, Boston Children’s Hospital, Boston, Massachusetts (Recko, Nuss); Clinical Research Program, Boston Children’s Hospital, Boston, Massachusetts (Huang). Corresponding Author: Heather C. Nardone, MD, Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803 (heather.nardone@nemours.org).

JAMA Otolaryngol Head Neck Surg . 2014;140(3):233-236. doi:10.1001/jamaoto.2013.6378 Published online January 16, 2014.

V ocal fold nodules (VFNs) are benign lesions that ap- pear at the junction of the anterior and middle thirds of thevocal fold. Theydevelopas a result of trauma aris- ing from contact between the opposing surfaces of the vocal folds, generally related to voice overuse or to repetitive vocal abuse and vocal strain. Multiple factors may act to create an environmentmore conducive toVFN formation, including gas- troesophageal reflux, allergy, sinusitis, postnasal drip, and chronic cough. There may be a genetic predisposition toward the development of nodules as well. 1 Among hoarse pediatric patients, VFNs are the most fre- quently found pathological condition of the larynx. 2 Their

prevalence among school-aged children is high, estimated at 16.9%. 3 Commonly used treatments for pediatric VFNs in- clude (1) behavioral management to guide children toward im- proved vocal hygiene, (2) direct voice therapy, and (3) treat- ment of exacerbating factors such as allergic rhinitis or gastroesophageal reflux. Surgery to remove VFNs is gener- ally reserved for patients with severe cases and those whose VFNs do not respond to more conservative treatment. Many clinicians advocate for conservative treatments ini- tially because VFNs resolve spontaneously at puberty in the majority of children, particularly in boys. 1,4 Vocal behaviors including excessive or aggressive voice use that may lead to

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